Can You Get Hepatitis C from Sex?

Despite Controversy, Risk Seen as High in Some Groups

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While injecting drug use remains the primary mode of transmission for the hepatitis C virus (HCV), an increasing focus has been placed the potential for infection through sexual contact. We say potential ­– as opposed to, say, risk or likelihood – as many experts still regard the concept of sexual HCV transmission as controversial. And, truth be told, the bulk of evidence seems to support this stance.

One study from the University of California, San Francisco in 2013 estimated that the risk of HCV among heterosexual couples was in the ballpark of one per 190,000 sexual contacts. Furthermore, the researchers concluded that the association between HCV and specific sexual acts was at best ambiguous and that mixed-status couples should be provided "reassuring counseling messages" as to the very low risk of infection.

More recent evidence, however, suggests that such reassurances don’t hold up as well in other groups. In fact, since 2004, a number of studies have concluded that the risk of HCV through sex is not only high among men who have sex with men (MSM) but is increasing—predominately among those infected with HIV.

Debating Sexual HCV Transmission in Gay Men

One of the first large-scale investigations was conducted in 2005 by the on-going, multi-center Swiss HIV Cohort Study. Evaluating data from 3,327 HIV-positive MSM from between 1988 and 2004 (and excluding those who injected drugs), the researchers found that the rate of infection among those who engaged in condomless sex was 300 percent greater than those who used condoms consistently.

This was in stark contrast to another study published in 2005 from the University of Quebec, which concluded there was no evidence of sexual transmission of HCV among MSM and that the sole cause of infection in their study population was injecting drug use. However, the study conclusions were strongly limited by the short period of surveillance (nine months between January and September 2001).

In was only in 2007 that more in-depth research (generally focused in larger, gay urban communities) began to contest traditional scientific opinion about sexual transmission among non-injecting MSM.

One cornerstone investigation from the Amsterdam Cohort Study, which retrospectively screened 1,836 MSM from 1984 to 2003, that the rate of sexual acquired HCV was not only higher among HIV-infected MSM but rate of infection has increased ten-fold. A review of hospitalization records further showed that, after 2000, 59 percent of the men had reported an ulcerative sexually transmitted infection, while 55 percent reported practicing "rough sex" (e.g., fisting). None of the men admitted to injecting drug use.

By 2009, another study from Amsterdam punctuated the impact of HIV on HCV transmission, wherein less than 1% in HIV-negative MSM were infected with HCV versus 17 percent of HIV-positive MSM. Of these, 82 percent reported no injecting drug use. Fisting, group sex, shared sex toys, and the use of the drug gamma hydroxyl butyrate (GHB) were identified as among the primary co-factors for infection in HIV-positive MSM.

A 2010 meta-analysis from the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention further demonstrated that fisting, as an independent factor, increased HCV risk by 500 percent in HIV-positive MSM—likely due to damaged or bleeding rectal tissues—while shared sex toys more than doubled the risk.

Gay Men May Not be the Only Ones at Risk

A number of recent studies have suggested that the risk of HCV through sex may not be limited to MSM. According to a 2009 study from Women’s Interagency Cohort Study, HCV risk among 3,636 HIV-positive women with no history of injecting drug use was twice that of HIV-negative women. In addition to HIV status, risk among women was associated with male sexual partners who were injecting drug users. Multiple sex partners, inconsistent condom use, poverty and unemployment were also seen to be contributing factors.

All told, the investigators concluded that the prevalence of HCV in this study population was 6.5%, suggesting that the counseling message to women needs to change,placing greater emphasis on the increased risk of HCV through sex—particularly those with HIV (or at risk of HIV), as well as those with male partners who inject drugs.


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